Provider Demographics
NPI:1134216609
Name:KEDZUF-MCGINNIS, LISA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:KEDZUF-MCGINNIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:KEDZUF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:9318 SCARLET OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-3901
Mailing Address - Country:US
Mailing Address - Phone:918-520-4344
Mailing Address - Fax:
Practice Address - Street 1:107 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4614
Practice Address - Country:US
Practice Address - Phone:918-358-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist